Care Partner Information Sheet

Discharge Journey: from Hospital to Home

A discharge is when a person leaves the hospital to go home. People can also be discharged from the emergency department (ED), nursing home or rehabilitation center.

Older adults and their caregivers need to know how to help the person to keep getting better. It is important to ask the questions below. Ask for the answers in writing.

What medications should they take, and what should they stop taking?

It is common for a person's medications to change. They need to know what new medications to take, and what to stop taking. Ask the doctor or nurse to write down the full list of what the person should take, what it is used for, side-effects, and when and how to take it. Ask where to pick up any medications on the list that are not in hand. Do not take any medications that are not on the new list.

What medical equipment does the older adult need?

An older adult sometimes needs a wheelchair, oxygen tank, or other medical equipment that they did not use before. Make sure to know what is needed, where to get it, and when and how to use it. Medicare will cover some of these expenses, but not all of them. It is important to ask if the item can be paid for by Medicare or the person's private insurance. If it cannot, the person may have to pay for it out-of-pocket.

What signs or symptoms should the patient look out for?

Patients discharged to home may get worse, or develop a new illness. Ask the doctor about what signs or symptoms to look for, and what to do if the person has those signs or symptoms.

What care is needed, and for how long?

Older adults may not be able to do all of the same things they did before. They may need more help walking, cooking, or doing other activities. They may also need special care, such as wound care. Ask where and how to get the needed care. If a family member must provide part or all of the care, be sure they know how. Tell the doctor or nurse if the needed care cannot be provided at home by a family member. One should not feel pressured to care for an older adult if they are not prepared - even if it is for a spouse or parent. It is okay to ask for help!

When does the patient need a follow up appointment?

Sometimes the date of the next medical appointment is written on the discharge papers. Other times, the patient or their family member will have to call to schedule it. Before going home, make sure to know when and where the next appointment is, or who to call to schedule it.

Is home health or other care support available?

It can be hard for a family caregiver to meet all of the new care needs after a discharge. One option is home health care. Home health care is when a nurse or physical therapist visits the home to help with medical care. Home health can be paid for by Medicare if the patient qualifies, and the services are ordered by a doctor. Ask if the doctor requested home health care services. Find out what care will be provided, and for how long. Other care support may be offered by local community services and volunteer programs. Most of the time, these services can only help with non-medical care needs. To find other care support services in the area, use the Eldercare Locator.

Who can be called with questions about care?

It is common to have more questions once at home. It is important to know who to call. Many hospitals have "transition specialists," or paid nurses and social workers that can provide help to the patient and their caregiver after a discharge. Ask if the hospital has this service, if it is paid for by insurance, and how to contact them. If transition specialists are not available, ask who can be called if additional help is needed.

What if the patient does not seem healthy enough to go home?

Patients and caregivers who think they are being asked to leave the hospital too soon can get help. In these cases, Medicare can help with a special group called the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO).

Individuals living in the western Pacific states (including Arizona, Nevada and Idaho), the Northeast (except Delaware, Maryland and Washington DC), and Puerto Rico should call Livanta at 866-815-5440. Individuals living in Delaware, Maryland, Washington DC., the South, Midwest and Rocky Mountain regions should call KePRO at 844-430-9504. Complaints can also be made by calling 1-800-MEDICARE.

Patients and caregivers who think they are being asked to leave a nursing home or rehabilitation center too soon can also get help from a local ombudsman program. Use the ElderCare Locator to find a local ombudsman, or call 1-800-677-1116. If possible, call before the person is discharged to home.


Written By: Melissa Elliott, MSW